Provider Demographics
NPI:1427274240
Name:SIMON, STEVAN (PT)
Entity type:Individual
Prefix:
First Name:STEVAN
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MERIDIAN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-1929
Mailing Address - Country:US
Mailing Address - Phone:617-561-7246
Mailing Address - Fax:617-561-7247
Practice Address - Street 1:50 MERIDIAN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-1929
Practice Address - Country:US
Practice Address - Phone:617-561-7246
Practice Address - Fax:617-561-7247
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10941225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0397831Medicaid
MAY68965Medicare ID - Type UnspecifiedPHYSICAL THERPAY REHAB